So Much to Learn, So Little Time
At Dallas’ Southwestern Medical School, one of the nation’s best research institutions, students not only have to master an exploding body of scientific knowledge—they also must learn to deal with social problems and a changing marketplace. No wonder becoming a doctor is harder than ever.
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The Biomedical Machine
MEDICAL EDUCATION IS ON THE THRESHOLD of its greatest pedagogic change since 1910, when educator Abraham Flexner published his scathing critique of medical schools in the nation, calling the vast majority of them quack factories. These were still the dark ages of medicine in America, when charlatans and magic elixirs, untrained midwives and the surgical anesthetic known as sour mash, still dominated health care. Doctors were counselors and confidants more than students of curative science. Since only about a dozen drugs were known to be pharmacologically effective, anyone with minimal powers of memorization and a reassuring voice could call himself a doctor—and that’s exactly what many people did.
Of the 150 or so medical schools in the nation at the time, Flexner recommended that 120 be summarily shut down. Most of them were little better than trade schools, where doctors learned a craft much as a carpenter or a mason might. Flexner’s recommendation, considered radical at the time, was to redefine the medical profession and the education necessary for it. The doctor should be a scientist who specialized in “derangement of biomedical function” and whose primary duty was to diagnose that derangement and prescribe cures. All other roles that society seemed inclined to foist on physicians—including the doctor’s time-honored function as a counselor—should be left to other professions. Aspiring physicians should learn as students, not as apprentices to other doctors; they should learn the basics of bioscience before they began treating patients; and medical school instructors should put teaching ahead of practicing medicine.
The idea was to train doctors to be more than purely reactive craftsmen who simply identified symptom X as associated with af�iction Y and prescribed cure Z, basing their decisions solely on past experience, with little understanding of medical science. Education rooted in the basic sciences sought to foster in the physician an understanding of the true nature of disease and health. Doctors needed to know which treatments worked and why they worked. The medical schools that taught them had to be traditional institutions of higher learning.
Flexner’s science-first model eventually became the norm for American medical education. As is the case at Southwestern today, students are first inundated with the basic sciences in the traditional lecture format, then slowly eased into clinical applications of their work at an adjacent teaching hospital. The strict academic environment was designed both to educate doctors and to promote scientific research and discovery by faculty members.
The boom years for medical schools began after World War II. The Manhattan Project had suggested to the country that monumental tasks could be accomplished by rigorously applied science. If Big Science could discover how to split atoms, why couldn’t it find cures for major diseases? Millions of dollars, both public and private, flowed into biomedical research, largely through the National Institutes of Health. At the same time, the post-war boom had produced shortages of suddenly vital goods and services—doctors among them. State legislatures hastily appropriated funds to build new universities and medical colleges in response to a government-proclaimed doctor shortage. For the first time, medical care became widely available—and affordable—to most Americans. The new biomedical machine began to produce impressive results. Preventions for age-old pathologies like polio were discovered, radiological diagnosis and surgical technique were refined, new wonder drugs were introduced to the market, and the more Big Medicine accomplished, the more the public demanded. In medical academe these accomplishments were seen as direct results of adherence to the Flexnerian creed: Science is king.
“Where Are the Patients?”
BIOCHEMISTRY IS STRAIGHT, UNADULTERATED SCIENCE of the sort that could glaze the eyes of even the most zealous scholar. This is the discipline of amino acids and metabolism, of complex lipids, of polysaccharides and DNA, of the functioning and dysfunctioning of the human body at its most elemental level—its chemistry. Learning it is a torturous exercise.
The biochemistry lecture hall, in a basement at Southwestern medical school, is an amphitheater shaped like a wedge of pie. It is in this moodily lit room that first-year students get their initial taste of pure medical science, and for many of them, it is an unpleasant experience.
Leslie Chin knew of the infamous first-year biochem through a relative who had studied at Southwestern four years before her. Still, she says, her reaction was, “This is med school! Where are the patients?” Leslie had long dreamed of being a doctor; and the dream had always involved putting her hands on a patient, diagnosing what was wrong, and curing it. Though she’d taken biochemistry at the University of Texas, it still seemed hopelessly abstract. In time though, she came to understand the warning of Dr. Lacey in that opening lecture: “The people who tell you biochemistry isn’t relevant are the people who make mistakes, because they don’t know biochemistry.”
“Biochem is the great leveler,” Leslie says after several weeks of the course. “It is where all of us—from biology majors like me to English majors—are in equally deep.” Each Monday, Wednesday, and Friday at nine in the morning, all two hundred first-year students gather to listen to one or another guest lecturer hold forth on subjects like amino acid metabolism. But even this most sacred of basic-science classes has been affected by the knowledge glut.
Lewis Waber, for example, who delivered the lecture on amino acid metabolism, was quick to advise his students of precisely how he wanted them to spend their time on his material—and how he didn’t want them to spend their time. “I do not want you to try to memorize metabolic pathways, the structures of metabolites, or the names of enzymes,” he wrote on the first page of his lecture outline. “You would not remember them long enough to do you any good.… I want you to try to see the interrelationships among metabolic pathways. I want you to understand how defects in one pathway cause derangements in others.” He peppered his lecture with jazzy computer-driven visuals and rock and roll music to keep the students’ attention. The class is another indication that the days when medical education was based on superhuman feats of rote memorization and regurgitation are mostly over. As in anatomy, most, if not all, of that sort of information can be retrieved from a database with a couple of keystrokes. The task of today’s medical student is to get a firm grasp of the motifs and principles that form the trunk of the information tree. That, educators have come to realize, is all there’s time for.
The students, for their part, have devised their own methods for coping with the explosion of knowledge. When Leslie Chin goes to biochem every other morning, she does so not just as a student but as an archivist for a special student-run service that provides complete transcripts of all lectures. Each lecture is taped, transcribed, proofed, and fact-checked by a team of students and provided to other students who have paid a $115 per-year fee for the transcriptions known in student jargon as scribes. “That’s mainly what I use to study,” says Leslie, “the scribes and the syllabus.” The service has the additional benefit of allowing students to skip lectures if they wish and use the time to study for other classes. In the age of the knowledge glut even the faculty sees nothing wrong with this. “Why, when I was a med student,” says Professor Burnside, “it was unheard of to miss a lecture. But it’s the times. It’s not like these students are goofing off when they skip a lecture. They’re at the computer or somewhere else, learning.”
Even with such time-management gimmicks, first-year students quickly are forced to adopt a Herculean study schedule. David Heise, for example, arises at four-thirty each weekday, fixes breakfast for himself, lunch for his two children, kisses his wife good-bye, and makes the long commute from his home in Plano to the Southwestern campus, near downtown Dallas. He attends biochem or another lecture starting at nine and finds himself either in class, lab, or a review session almost nonstop until five. Then he returns home, grabs some dinner, and studies until eleven. “There’s really no other way,” he says. “Because of my experience in business, I know a lot more about time management than some of the younger students. But it just requires time.”
The Southwestern Gospel
THE DEDICATION TO BASIC BIOMEDICAL SCIENCE at Southwestern remains so intense because for this once-obscure medical school in the hinterlands, science has been the school’s entrée to academic celebrity. Although the Southwestern name has been around Dallas since 1900, its early history was less than auspicious, and it didn’t show up on any radar screen outside Texas until its medical researchers won three Nobel prizes for medicine in the past eleven years.
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